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New Provider Form

LifeServices values our strong professional relationships with affiliates who can provide the highest quality of services within their areas of clinical specialties.  Our network offers licensed EAP counselors who specialize in a wide range of problems including marital and family issues, child/adolescent problems, alcohol and drug abuse, critical incident debriefings, and much more.

LifeServices EAP is continuously expanding our provider network of licensed counselors to better serve our existing and new customer base. If you are interested in becoming a LifeServices EAP provider please complete and submit the information below.

First Name
Last Name
License Type
Group Name (if applicable)
E-mail Address
Address Line 1
Address Line 2
City
State
Zip Code
Daytime Phone
Fax
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